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Based on staff interview and record review, the Critical Access Hospital (CAH) failed to ensure that sufficient staffing was available at all times to prevent non-employees from delivering patient care services in the Emergency Department for 1 out of 10 applicable patients. (Patient #1). Findings include:

Per record review, Patient #1 presented to the Emergency Department (ED) on 4/18/2018 at 19:41 with the chief complaint of a psychiatric problem. Patient #1 arrived at the ED via ambulance following a well-person check which found Patient #1 in their home, "tearful with a scarf around his/her neck with 6 near new cuttings on Left forearm perhaps 3 days old". A nursing assessment indicated Patient #1 presented with symptoms of depression and anxiety. Per nursing documentation, "patient currently admits to suicidal ideation. The patient admits to planning to cut him/herself. There was associated agitation and anxiety". Patient #1 was subsequently evaluated by a mental health crisis clinician and was determined to meet criteria for involuntary psychiatric treatment.

Per review of nursing notes, ED staff and police officers monitored Patient #1 upon arrival. Approximately 30 minutes after arrival, Patient #1 "became angry and jumped off the bed saying s/he was leaving". Police officers placed Patient #1 in handcuffs and, "over the course of the next 20 minutes s/he calmed, relaxed and cuffs were removed." A brief time after the handcuffs were removed, Patient #1 attempted to leave the facility again and CAH staff and two police offices applied leather restraints to secure Patient #1's extremities to the bed.

During an interview on 5/29/2018, an ED technician confirmed that two police officers were present with Patient #1 in his/ her room in the Emergency Department. The ED technician stated that shortly after arrival, Patient #1, "became belligerent" and "attempted to bolt" from the facility. Per the ED technician's observations, the two police officers held Patient #1's arms and handcuffs were applied. Patient #1 calmed, and the handcuffs were removed approximately 20 minutes later. Patient #1 again tried to run from the room and leave the facility. The ED Registered Nurse and police officers applied leather restraints. Patient #1 calmed, and the leather restraints were removed 45 minutes after being applied. Per interview, the ED technician stated that Patient #1 was not under arrest nor had been charged with a crime.

Per review of the April 2018 ED department records, the staff schedule included 3 Registered Nurses, 1 Registered Nurse Team Leader, and 1 ED technician at the time Patient #1 was admitted. During an interview, the ED Medical Director stated that additional staff available to respond to psychiatric emergencies during night shift hours may include personnel from maintenance, housekeeping and the Nursing Supervisor. Scenarios in which the police department may be contacted by the Emergency Department for assistance include instances when an employee has been assaulted, situations when a crime has been committed, or when a dangerous situation is present after, "all attempts at de-escalation" have been tried.

Per review of the CAH policy, "Police Assistance, Emergency Department" (current version date 05/29/2015), Policy Provision #1 states, "When police personnel are present with a disorderly patient/ person, ED staff is responsible for medical care of the patient. Police may assist in controlling violent and/or threatening behavior." Per interview on 5/30/2018, the Director of Quality stated that the expectation is that police officers, "will not be used during a restraint unless the patient is under custody." S/he confirmed there was no evidence of Patient #1 being in protective custody of the police and that police officers used handcuffs to restrain Patient #1 on 4/18/2018.

The failure to have adequate numbers of trained hospital staff present and available to provide necessary patient care in the Emergency Department was confirmed during interview with the Director of Quality on 5/30/2018 at 1:00 PM.

Based on staff interview and record review, the CAH failed to ensure that care was provided in accordance with written policies and procedures regarding the use of restraints for 1 of 2 applicable patients. (Patient #2)

On 5/13/18 Patient #2 was brought to the ED by police with a chief complaint of a psychiatric problem presenting with agitation, bizarre behaviors, intoxication by alcohol and audio and visual hallucinations. An Emergency Evaluation was conducted by Lamoille County Mental Health (LCMH) which determined Patient #2 was in need of involuntary psychiatric hospitalization. Due to lack of an available psychiatric hospital bed, Patient #2 was held in the ED until transfer on 5/21/18. The patient was assigned to room 7 (identified as the ED's safe room) and 1:1 sitters were utilized 24/7. During the first 72 hours after ED admission, on 2 separate occasions, staff placed Patient #2 in 4 and 5-point restraints.

On 5/14/18 at approximately 10:30 while escorting Patient #2 to the bathroom, the patient hit a staff member's hand. While returning the patient back to Room #7, Patient #2 hit and pushed a staff member in the chest. It was determined Patient #2 required restraints and 5-point restraints were applied by ED staff. Besides restraints, the ED physician ordered involuntary emergency medications to be administered to Patient #2. The medications included: Haldol 10 mg (antipsychotic), Ativan 2 mg. (antianxiety) and Benadryl 50 mg and were all administered by intramuscular injection (IM) at 10:52. Per review of Violent Restraint 1:1 Documentation Tool completed by ED nurses a trial removal of left leg restraint was performed at 11:45. Patient #1's behavior was recorded as "asleep". At 12:15 the chest restraint was removed, and the patient's behavior was "cooperative" & "calm". From 12:30 to 13:30 Patient #2's left & right arm and right leg remained restrained and nursing documented the patient as "sleeping", but "verbally abusive -whispering to him/herself" when awakened and when fluids were offered. From 13:45 to 15:30 Patient #2 remains in restraints and behavior is described as "asleep 1/2 time" but when awakened by staff becomes agitated and was reminded s/he is hospitalized. Per review of 1:1 Observation/Documentation Tool (completed by staff assigned to provide constant observations) documentation on 5/14/18 from 14:45 to 16:45 indicates the patient was "calm/cooperative" and/or "asleep". Patient #2 remained restrained for 6 hours & 45 minutes although the patient had demonstrated during this time to be calm and cooperative and often sleeping. Staff failed to discontinue the restraints at the earliest possible time waiting until 16:45 when the upper and lower restraints were removed.
In addition, on 5/15/18 Patient #2 was placed in 4-point restraints after staff determined Patient #2 was unsteady on his/her feet and was not accepting redirection. At 05:30 Patient #2 was placed in restraints and the patient's behavior was documented by nursing staff on the Violent Restraint 1:1 Observation Documentation Tool to be "agitated" and "combative". From 06:30 to 07:30 Patient #2 was observed "asleep". Three of the restraints were released at 07:30 to allow the patient to void, and the patient requested breakfast and restraints were reapplied. At 08:15 Patient #2 was documented as "calm". It was not until 10:15 when the patient was finally released from all 4 restraints.

Per review of policy, "Restraints" (approved 5/2/16) "Policy Statement: Copley Hospital's goal is to support and maintain patient health and safety and to preserve patient dignity, rights and well-being. All patients have the right to be free from restraint or seclusion unless medically necessary or is used to ensure the safety of the patient, staff member, or others". During both applications of restraint use on 5/14/18 and 5/15/18 there were documented periods when Patient #2 was calm and/or asleep demonstrating s/he was no longer posing an immediate threat to the safety of the patient or staff. Further review of the CAH policy, "Restraints" also states, "Restraint is used only when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm." Least restrictive interventions were not initiated on 5/15/18 at 05:30 prior to implementing 4-point restraints for the purpose of containing Patient #2 on the ED stretcher. Although Patient #2 was unsteady on his/her feet because of medications administered by staff, no other attempts were made to direct the patient to an alternative option, such as a recliner, to sit and rest prior to the application of restraints.

Per interview on 5/29/18 at 9:53 AM. The ED nurse manager confirmed there were potential opportunities to have discontinued the use of restraints on 5/14/18 and 5/15/18, acknowledging staff failed to release restraints at the earliest possible time. The ED nurse manager further acknowledged although s/he had not reviewed each restraint episode and staff documentation for the use of restraints, the application of restraints on 5/15/18 would certainly require further analysis for the use and least restrictive alternatives.

Based on staff interviews and record review, the CAH failed to effectively analyze and evaluate the use of restraints in the Emergency Department, resulting in a failure to identify opportunities for improvement in the delivery of patient care for 2 out of 10 applicable patients. (Patient #1 and Patient #2). Findings include:

During an interview on 5/30/2018. the facility's Clinical Educator discussed the process for monitoring the use of restraints. A restraint tool titled, "Nursing Restraint-Seclusion Documentation Checklist" is utilized to audit for specific documentation required in the medical record. Required documentation includes patient behavior, clinical indications for the restraint, physician order requirements, patient behavior observations, and nursing care provided during each episode of restraint. Per interview, the Clinical Educator stated that the audit tool is completed via a peer-review process by Registered Nurses. Per directions on the "Nursing Restraint-Seclusion Documentation Checklist", the form is to be reviewed by the department manager after its completion, then sent to the Quality Department.

Despite the current peer-review process of auditing following utilization of restraints, nurse surveyors identified two separate occasions where the hospital failed to follow policy and procedures regarding the use of restraints. Staff had failed to discontinue restraint use at the earliest possible time during a restraint with Patient #2 on 5/14/2018 and 5/15/18. Non-hospital staff handcuffed a patient who was not under protective custody, and police officers assisted in the application of leather restraints with Patient #1 on 4/18/2018. Per interview with the Director of Quality on 5/30/2018 at 1:00 PM, the Quality Department receives notification when a restraint occurs, the information is maintained on a facility-wide restraint log, and a quality review is conducted of the restraints. The Director of Quality confirmed that the Quality Department had received the completed audit tool checklists regarding 3 episodes of restraint that occurred in the Emergency Department on 5/14/2018, 5/15/18 and 4/18/2018, however a review or analysis of the episodes had not been subsequently conducted.

The present chart auditing process had not captured the issues in provision of patient care services in the Emergency Department. As a result, the opportunity to correct and improve the implementation of restraints, to expand staff education, or to prevent the use of non-hospital staff in the provision of direct patient care had not been identified or addressed.